Association of HIV Infection With Cardiovascular Pathology Based on Advanced Cardiovascular Imaging
Authors: Jonathan A. Hudson, Edith D. Majonga, Rashida A. Ferrand, Pablo Perel, Shirjel R. Alam, Anoop S. V. Shah
Journal: JAMA (2022)

<h3>Importance</h3> HIV-associated cardiovascular disease is increasing in prevalence, but its mechanisms remain poorly understood. <h3>Objective</h3> To systematically review data from advanced cardiovascular imaging studies evaluating computed tomographic coronary angiography, positron emission tomography (PET), and cardiac magnetic resonance (MR), in people living with HIV compared with uninfected individuals. <h3>Data Sources</h3> Three databases and Google Scholar were searched for studies assessing cardiovascular pathology using<i>computed tomographic coronary angiography</i>,<i>cardiac MR</i>,<i>PET</i>, and<i>HIV </i>from inception to February 11, 2022. <h3>Study Selection</h3> Two reviewers selected original studies without any restrictions on design, date, or language, investigating HIV and cardiovascular pathology. <h3>Data Extraction and Synthesis</h3> One investigator extracted data checked by a second investigator. Prevalence ratios (PRs) and differences in inflammation among people living with HIV and uninfected individuals were qualitatively synthesized in terms of cardiovascular pathology. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for observational studies. <h3>Main Outcomes and Measures</h3> Primary outcomes were computed tomographic coronary angiography–defined moderate to severe (≥50%) coronary stenosis, cardiac MR–defined myocardial fibrosis identified by late gadolinium enhancement, and PET-defined vascular and myocardial target to background ratio. Prevalence of moderate to severe coronary disease, as well as myocardial fibrosis, and PRs compared with uninfected individuals were reported alongside difference in vascular target to background ratio. <h3>Results</h3> Forty-five studies including 5218 people living with HIV (mean age, 48.5 years) and 2414 uninfected individuals (mean age, 49.1 years) were identified. Sixteen studies (n = 5107 participants) evaluated computed tomographic coronary angiography; 16 (n = 1698), cardiac MRs; 10 (n = 681), vascular PET scans; and 3 (n = 146), both computed tomographic coronary angiography and vascular PET scans. No studies originated from low-income countries. Regarding risk of bias, 22% were classified as low; 47% moderate; and 31% high. Prevalence of moderate to severe coronary disease among those with vs without HIV ranged from 0% to 52% and 0% to 27%, respectively, with PRs ranging from 0.33 (95% CI, 0.01-15.90) to 5.19 (95% CI, 1.26-21.42). Prevalence of myocardial fibrosis among those with vs without HIV ranged from 5% to 84% and 0% to 68%, respectively, with PRs ranging from 1.01 (95% CI, 0.85-1.21) to 17.35 (95% CI, 1.10-274.28). Differences in vascular target to background ratio among those with vs without HIV ranged from 0.06 (95% CI, 0.01-0.11) to 0.37 (95% CI, 0.02-0.72). <h3>Conclusions and Relevance</h3> In this systematic review of studies of advanced cardiovascular imaging, the estimates of the associations between HIV and cardiovascular pathologies demonstrated large amounts of heterogeneity. The findings provide a summary of the available data but may not be representative of all individuals living with HIV, including those from low-income countries with higher HIV endemicity.